Category Archives: laparoscopic abdominal hysterectomy

Last Thursday I walked into the conference room at 7:00AM and it was dark and deserted. I then remembered Grand Rounds are on Thursday! Whoops. My school schedule in the fall kept me busy on Thursdays so I guess it slipped my mind. I checked the OR board and saw a couple interesting things happening at 8:30 so I killed time until then.

I chose a laparoscopic hysterectomy with Drs. Edraki and Tukenmez and an MS-3 named Veronica. Dr. Edraki was a bit late arriving as he is not based at Highland and had to drive in for the procedure against some traffic. After a digital pelvic exam, the surgeons spent some time positioning the patient optimally on the table. She was obese, so it took some effort from the team. There was also a big problem with the holstering of the patient for the procedure. The positioning required for the laparoscopic nature of the procedure required the patient to be tilted head down, legs up and apart, arms at her side. The apparatus used was an inflatable “bean bag” that gripped the patient. The problem was that no one in the OR had used it before, and couldn’t get it quite stabilized. The patient was showing signs of slipping in position. It was clear that no one was able to remove the bag from under her to try and figure out the best way to attach it to the operating table, especially since at this point, the patient was already attached to IVs, anesthetized, etc.

Dr. Edraki made the call to operate traditionally, as there was no strange positioning necessary, and over half an hour had been wasted deliberating on the positioning of the patient. It was a bit tense in the room–clearly a frustrating situation for everyone on the team–right down to the surgical tech, who had to change up all her tools at the last minute!

I was looking forward to finally seeing a uterus. Our female cadaver in anatomy class was missing her uterus due to cancer (unfortunately, just like the patient I was observing now) and I wanted to see a uterus in person. (That sounds strange to say, but if anyone understands that, it’s you guys, right?) The patient was adjusted to lay flat, and sterilization began. I really couldn’t get a great vantage point for this surgery even though I did get a step at one point. I did see Dr. Edraki start with quite a long incision that seemed to span from the pubic bone to near the belly button. He made quick work of getting down past the fat and muscle, and they set up an apparatus around the incision as a framework for tools to hold the intestines out of the way. I couldn’t actually see anything beyond this, but could see Dr. Edraki placing several laps in the cavity, I think to isolate the uterus. He began tying suture lines in various places, and doing lots of work involving scalpel, bovie and suction. He spoke to the medical student occasionally, pointing out landmarks and asking her questions. I had no idea the open hysterectomy was so invasive in terms of the open access to the thoracic cavity. It sounded like an incredible anatomy lesson and I wished for a GoGo Gadget Neck to crane over and watch more closely. Finally I saw them lift up the uterus and hand it to the surgical tech. They had to page a pathologist to come and test some of the tissues to confirm cancer. I am not sure quite what the situation was, but obviously the patient was getting the uterus removed regardless so perhaps there were masses felt during palpation prior to surgery that were not confirmed cancer. At any rate, pathology needed to report back during the surgery, because if they did detect cancerous cells in the tissue, Dr. Edraki explained he would be taking tissue from the pelvic and aortic lymph nodes. I couldn’t tell if this was to remove the nodes completely due to cancerous growth, or to simply test samples from each node to monitor the spread of the cancer.

Pathology came and took the uterus and then everyone basically just waited around for 20 minutes over the open cavity. Dr. Tukenmez and Dr. Edraki chit chatted a bit, and Dr. Tukenmez asked Dr. Edraki’s opinion on a situation she had with another patient. Dr. Edraki gave more awesome anatomy lessons to Veronica. Gentle hold music played in my head.

The pathologist came back and reported that he did see “grade 1” (I think) tissue abnormalities, and some other things that I didn’t catch, but the upshot was that it indeed was cancer, and the patient’s lymph nodes needed to be sampled/removed. Dr. Edraki lengthened the incision significantly up the thoracic area. It looked like he added several inches onto the incision. This gave him access all the way up to the patient’s aortic lymph nodes. He worked carefully, gathering several tissue samples from the left and right pelvic lymph nodes, pointing out more anatomy to Veronica, and rejiggering the resecting tools as he switched sides. Interestingly, he had to ask the CRNA to relax the patient at a few different points during this stage of the operation, as she was pushing back against his tools with her abdominal muscles. It’s so crazy to think how “dynamic” anesthesia is. I don’t even know if that’s the right word, but there are so many levels to consciousness and to sub-consciousness. Prior to OREX, if someone told me that people starting to wake up during surgery is not uncommon, I would have not believed them. But it’s true! There are so many levels to “waking up” and the maintenance of anesthesia is such an active part of surgery. After quite a while excising lymph tissue from the left and right pelvic nodes, the surgeons moved on to the aortic nodes. First Dr. Edraki reached pretty far in and palpated the area around the aortic lymph nodes. He instructed Veronica to reach in and feel where his hands were and she murmured in amazement. I think he was instructing her to feel the heart or lungs. He took tissue from the right side, and then had to take greater care on the left side due to proximity to parts of the heart.

After the tissue samples were all collected, it was time to close up. The surgery ended up taking a few hours all told, and it ended up not being too bad that they couldn’t go in laparoscopically given the need to take the extensive tissue sampling. They possibly would have had to open up anyway during that portion.

Dr. Harken’s lecture focused on the treatment of venous thromboembolism and the problems with blood coagulation. The lecture was complex and fast-paced, and I found it challenging to keep up and understand the overall picture. First, Dr. Harken discussed the diagnosis of an illness named BPT. The symptoms include pain, swelling, and skin changes. Diagnosis can be further verified by an ultrasound, which has an accuracy of 70%, and a venogram measurement, which has an accuracy of ~100%. Dr. Harken then went on to discuss the differences between patient groups (e.g. medical patient vs. ICU medical patient vs. general surgery patient) and the unique risks they each face. For instance, stasis, hypercoagulability and tissue damage are some problems that afflict general surgery patients. From this topic, Dr. Harken segued into a quick overview of the coagulation cascade and the two pathways that define it: that resulting from damaged surfaces and that resulting from trauma. Heparin, a blood thinner, was reintroduced. Dr. Harken posed a question to the residents: “what happens when someone starts bleeding from Heparin?” The answer was to simply wait and give the patient blood since Heparin has a short half-life. The alternative is to give protamine, a drug that binds to heparin to reverse the anti-coagulating effect, with calcium, which counteracts the hypotensive affect of giving too much protamine. To conclude the lecture, Dr. Harken discussed two papers that focused on anti-coagulation drugs (for one of the papers, he notes that more than half of the writers were employees of the company that manufactured the tested drugs, suggesting the pressure for positive results and thus the presence of bias)

The first surgery I observed was a bilateral laparoscopic tubal ligation. The attending was Dr. Valentine, and Dr. Lee assisted him. The patient was a middle-aged, Hispanic woman. To prepare her legs were slightly elevated – almost as if she were giving birth – and her arms were placed near perpendicular to her sides. During this time, Dr. Valentine introduced himself to me and explained that the patient was getting “her tubes tied.” When Dr. Lee arrived at around 8:30AM, the surgery began. First, the patient was fitted with a catheter. When this was completed, Dr. Lee and Dr. Valentino made incisions on the belly button to create an opening for the laparoscopic portals, or trocars. Two additional trocars were inserted on the lower left and right abdomen. The insertion of these devices was quick, and soon enough, the laparoscopic camera and instruments were inserted. Using the laparoscopic instruments, which appeared to burn through and then seal the tissue, Dr. Valentine and Dr. Lee removed both of the fallopian tubes. To my surprise, the phrase “getting one’s tubes tied” was a misnomer – the fallopian tubes were not constricted but removed completely.

Once the procedure was completed, Dr. Lee told me that there was an alternative called Essure. For the Essure procedure, the patient is often left awake. The doctor would go through the vagina to place implants into the two fallopian tubes. These implant cause scarring and will ultimately seal the tubes if everything goes as plan. According to Dr. Lee, Essure is safer than bilateral tubal ligation because no incisions are made and general anesthesia is avoided. The downside to Essure is that the process is lengthy and not foolproof as complete removal of the tubes (if the implants do not seal the tubes fully, then the procedure fails).

Following the tubal ligation, I stayed to watch the next scheduled operation, which was a laparoscopic abdominal hysterectomy (the removal of the uterus). For this case, Dr. Lee was the main attending, with Dr. Valentine assisting her. The patient was a middle-aged, African American woman. The set-up and patient preparation was more or less the same as the previous operation: the positioning of the patient, the location of the incisions, the positioning of the laparoscopic instruments, etc. The first structure to be removed was a T-fibroid, or a mass of muscle, on the abdomen. The fibroid was like a golf ball in terms of size, shape, and color. Once this structure was removed, Dr. Lee and Dr. Valentine turned their attention to the connective tissue linking the uterus to the abdomen wall. Using the laparoscopic instruments, they slowly worked their way through the connective tissue. After reaching a certain depth, the amount of blood flowing into the abdomen increased. The problem of blood proliferation became a concern, and a suction tube (as well as new laparoscopic instruments) was brought in. However, neither of the doctors was truly alarmed, so I don’t think that it was an emergency. After Dr. Lee and Dr. Valentine worked their way through half of the uterus’ base on the abdomen, I excused myself for the day.